Standard Form 424 (R&R) - HRSA

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These are all required fields . Date Signed: If you are submitting this electronically please print off a copy of the face/cover pages of the application, sign and send them to HRSA’s Grants Application Center (GAC) –( See the program guidance for the GAC’s address) Note: Applicant applying in paper must send their entire grant application with the signed face/cover pages to the GAC 20. Pre-Application This is Not applicable to HRSA. A limited number of HRSA programs require a Letter of Intent which is different from a preapplication. Information required and the process for submitting such a Letter of Intent is outlined in the funding opportunity announcements for those programs with such a requirement. . INSTRUCTIONS FOR 5161 CHECKLIST (This is used for the 424 R&R as well) Field Type of Application Part A Part B Part C Business Official to be notified if an award is to be made Instructions Check one of the boxes corresponding to one of the following types: - New: A new application is a request for financial assistance for a project or program not currently receiving DHHS support. -Non competing Continuation: A non-competing application for an additional funding/budget period for a project within a previously approved project period - Competing Continuation ( same as Renewal from 424R&R face page) –this is a request for an extension of support for an additional funding/budget period for a project with a projected completion. - Supplemental (same as Revision from 424 R&R face page) An application requesting a change in the Federal Governments financial obligation or contingent liability from an existing obligation. Leave this Section Blank Leave this Section Blank In the Space Provided below, please provide the requested information Enter the name of Business Official to be notified if an award is to be made. Enter the Prefix, First Name, Middle Name and Last Name and Suffix (if applicable) of the Business Official and the organization. Enter the Address Street1 enter the first line of the street address of the Business Official. In Street2 enter the second line of the street address for the AR/AO, if applicable. Enter the City, County and State, Zip Code and Country of the business 4
Project Director/Principle Investigator designated to direct the proposed project official. Enter the Telephone and Fax number as well as the E- MAIL address of Business Official. Enter the Applicant Organizations 12 Digit DHHS EIN ( if already assigned) – This should be the same information as supplied in file number 5 of the 424 R&R face page . Enter the name of Project Director/Principle Investigator (PD/PI) – this should be the same information as supplied on the 424 R & R face page field number 15. Enter the Prefix, First Name, Middle Name and Last Name and Suffix (if applicable). Enter the name of the primary organization and Address: Street1 enter the first line of the street address of the AR/AO for the project. In Street2 enter the second line of the street address for the AR/AO, if applicable. Enter the City, County and State, Zip Code and Country of the PD/PI. Enter the Telephone Number, E-Mail and Fax number. DO NOT enter the social security number. Enter the highest degree earned for the PD/PI. INSTRUCTIONS FOR R&R SENIOR/KEY PERSON PROFILE Starting with the PD/PI, provide a profile for each senior/key person proposed. Unless otherwise specified in an agency announcement senior key personnel are defined as all individuals who contribute in a substantive, measurable way to the execution of the project or activity whether or not salaries are requested. Consultants should be included if they meet this definition. For each of these individuals a Biosketch should be attached which lists the individual’s credentials/degrees. Field Prefix First Name Middle Name Last Name Instruction Ex. Mr., Ms. Mrs. Rev. Enter the Prefix for the Individual identified as a key person for the project. If this is the entry for the Project Director and you are submitting electronically this field will be prepopulated with the prefix for the project director identified on the face page of the 424 R&R. This is the first (given) name of the Individual identified as a key person for the project. If this is the entry for the Project Director and you are submitting electronically this field will be prepopulated with the name of the project director identified on the face page of the 424 R&R. This is the middle name of the Individual identified as a key person for the project. If this is the entry for the Project Director and you are submitting electronically this field will be prepopulated with the name of the project director identified on the face page of the 424 R&R. This is the last name of the Individual identified as a key person for the project. If this is the entry for the Project Director and you are submitting electronically this field will be prepopulated with the last name of the project director identified on the face page of the 424 5
Page 1 and 2: complete the fillable SF-424 R&R. T
Page 3 and 4: SF 424 (R&R) APPLICATION FOR FEDERA
Page 5 and 6: PHS-5161-1 (7/00) PART D: A private
Page 7 and 8: RESEARCH & RELATED Project/Performa
Page 9 and 10: RESEARCH & RELATED BUDGET - SECTION
Page 11 and 12: RESEARCH & RELATED BUDGET - Cumulat
Page 13 and 14: OMB Approval No. 0348-0040 ASSURANC
Page 15 and 16: RESEARCH & RELATED Other Project In
Page 17 and 18: Instructions for the SF424 R&R (Res
Page 19: project ( ex. states, counties, cit
Page 23 and 24: Phone Number Fax Number Email addre
Page 25 and 26: INSTRUCTIONS FOR R&R BUDGET Section
Page 27 and 28: ($) Funds Requested ($) Total Numbe
Page 29 and 30: SECTION D. Travel Field Name Domest
Page 31 and 32: RESEARCH AND RELATED BUDGET - SECTI
Page 33 and 34: ($) Funds Requested Cognizant Feder
Page 35 and 36: Direct Costs category. 9. Other 2 T
Page 37 and 38: 4.b. If yes, please explain 4c. If

Standard Form 424 (R&R) - HRSA

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